Consensus statements on osteoporosis diagnosis, prevention, and management in the Philippines

Asia-Pacific consensus on long-term and sequential therapy for osteoporosis

Objectives

This study aimed to present the Asia-Pacific consensus on long-term and sequential therapy for osteoporosis, offering evidence-based recommendations for the effective management of this chronic condition. The primary focus is on achieving optimal fracture prevention through a comprehensive, individualized approach.

Methods

A panel of experts convened to develop consensus statements by synthesizing the current literature and leveraging clinical expertise. The review encompassed long-term anti-osteoporosis medication goals, first-line treatments for individuals at very high fracture risk, and the strategic integration of anabolic and antiresorptive agents in sequential therapy approaches.

Results

The panelists reached a consensus on 12 statements. Key recommendations included advocating for anabolic agents as the first-line treatment for individuals at very high fracture risk and transitioning to antiresorptive agents following the completion of anabolic therapy. Anabolic therapy remains an option for individuals experiencing new fractures or persistent high fracture risk despite antiresorptive treatment. In cases of inadequate response, the consensus recommended considering a switch to more potent medications. The consensus also addressed the management of medication-related complications, proposing alternatives instead of discontinuation of treatment.

Conclusions

This consensus provides a comprehensive, cost-effective strategy for fracture prevention with an emphasis on shared decision-making and the incorporation of country-specific case management systems, such as fracture liaison services. It serves as a valuable guide for healthcare professionals in the Asia-Pacific region, contributing to the ongoing evolution of osteoporosis management.

GRADE-ADOLOPMENT of clinical practice guideline for postmenopausal osteoporosis management-a Pakistani context

Due to its high prevalence, we aimed to create postmenopausal osteoporosis clinical practice guideline via GRADE-ADOLOPMENT for Pakistan. We recommend a higher dose (2000-4000 IU) of vitamin D for osteoporotic patients who are old, have malabsorption, or are obese. The guideline will help standardize care provision and improve health care outcomes for osteoporosis.

PURPOSE

Postmenopausal osteoporosis affects one in every five postmenopausal women in Pakistan. An evidence-based clinical practice guideline (CPG) is needed to standardize care provision to optimize health outcomes. Hence, we aimed to develop CPG for the management of postmenopausal osteoporosis in Pakistan.

METHODS

The GRADE-ADOLOPMENT process was used to adopt (as is or with minor changes), exclude (omit), or adapt (modify based on local context) recommendations to the source guideline (SG)-clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update from American Association of Clinical Endocrinology (AACE).

RESULTS

The SG was "adoloped" to cater to the local context. The SG consisted of 51 recommendations. Forty-five recommendations were adopted as is. Due to unavailability of drugs, 4 recommendations were adopted with minor changes, and one was excluded, while one recommendation was adopted with the inclusion of use of a surrogate FRAX tool specific for Pakistan. One recommendation regarding vitamin D dosage was adapted to recommend a dose of 2000-4000 IU of vitamin D in patients with obesity, malabsorption, and old age.

CONCLUSION

The developed Pakistani postmenopausal osteoporosis guideline consists of 50 recommendations. The guideline created recommends a higher dose (2000-4000 IU) of vitamin D for patients who are old, have malabsorption, or are obese, which is an adaptation from the SG by the AACE. This higher dose is justified as lower doses prove to be suboptimal in these groups and should be complemented with baseline vitamin D and calcium levels.

Intervention thresholds to identify postmenopausal women with high fracture risk: A single center study based on the Philippines FRAX model

Objectives

This study is designed to estimate appropriate intervention thresholds for the Philippines Fracture Risk Assessment Tool (FRAX) model to identify postmenopausal women with high fracture risk.

Methods

Age dependent intervention thresholds were calculated for a woman of body mass index 25 kg/m² aged 50-80 years with a previous fragility fracture without other clinical risk factors. Fixed thresholds were developed using a database of 1546 postmenopausal women who underwent dual-energy X-ray absorptiometry for clinical reasons. Major and hip fracture risks were estimated using clinical risk factors with and without bone mineral density (BMD) input. Women were categorized to high risk and low risk groups according to the age dependent thresholds. The best cut-points were determined considering the optimum sensitivity and specificity using receiver operating characteristic analysis.

Results

The age dependent intervention thresholds of major fracture risk ranged from 2.8 to 6.9% while hip fracture risk ranged from 0.4 to 3.0% between 50 and 80 years of age. Major fracture threshold of 3.75% and hip fracture threshold of 1.25% were the best fixed thresholds observed and non-inclusion BMD in the fracture risk estimations did not change the values. As a hybrid method, 3% major fracture and 1% hip fracture risks for those < 70 years old and age-dependent thresholds for those aged 70 years and above can be recommended.

Conclusions

The intervention thresholds estimated in the current study can be applied to identify Filipino postmenopausal women with a high fracture risk. Clinicians should decide on the type of thresholds most appropriate.

Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region

Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.

PURPOSE

Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.

METHODS

We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.

RESULTS

Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.

CONCLUSION

The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Osteoporosis guidelines from a rehabilitation perspective: systematic analysis and quality appraisal using AGREE II

INTRODUCTION

People affected by osteoporosis and fragility fractures often report disability and poor health-related quality of life. Albeit rehabilitation has a crucial role in older people, post-menopausal women and other subjects with high risk of fragility fractures, the rehabilitation perspective has been poorly investigated in the available guidelines for osteoporosis. The aim of this systematic review was to systematically evaluate the quality of guidelines for osteoporosis from a rehabilitation perspective.

EVIDENCE ACQUISITION

On May 2020, we performed a systematic search on medical literature of all guidelines published in the last 10 years on PubMed, Pedro, and international guideline databases. The study selection was based on key terms "exercise," "physical activity" or "rehabilitation." All authors independently assessed the methodological quality through the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, consisting of six domains (scope, stakeholder involvement, rigor and development, clarity of presentation, applicability, editorial independence).

EVIDENCE SYNTHESIS

Out of 331 documents retrieved, a total of 34 guidelines were selected after the screening phases. Twenty (58.8%) high quality guidelines were reported. According to AGREE II instrument, a mean score of 78.1±21.8% was reported for "scope and purpose" domain; for stakeholder involvement, the mean score was 58.1±22.1%; the rigor of development was good (mean score of 61.3±27.3%); for clarity of presentation the mean score was 79.4±20.3%; the applicability was poor (mean score of 30.9±25.2%); for editorial independence the mean score was 75.1±24.6%. Rehabilitation recommendations for osteoporotic patients were reported in 21 (61.8%) of the selected guidelines.

CONCLUSIONS

This is the first systematic analysis evaluating quality of the guidelines for osteoporosis using AGREE II instrument. Starting from a state of the art of the currently available evidence, we could conclude that therapeutic exercise at moderate to high intensity is encouraged by several guidelines for the management of people with osteoporosis and fragility fractures. More than half of guidelines were of high-quality. However, most guidelines are lacking specific indications about exercise features. This study might support the implementation of a rehabilitation perspective in the guidelines for osteoporotic patients.

Adaptation of clinical practice guidelines for osteoporosis in a Mexican context. Experience using methodologies ADAPTE, GRADE-ADOLOPMENT, and RAND/UCLA

High quality guidelines are required to enhance clinical practice, but its development is time consuming and a complex process. Adaptation might shorten development time and prevent double effort adjusting recommendations for a local context.

BACKGROUND AND OBJECTIVE

The aim of this article is to present our experience in a process in which we combined two methodologies for the adaptation of high quality osteoporosis CPGs for a primary health care context, with the inclusion of a formal consensus.

METHODS

We began an adaptation process with ADAPTE, and required to migrate to GRADE-ADOLOPMENT methodology, based on GIN-McMaster Guideline Development Checklist. To identify high quality clinical practice guidelines, we performed a systematic review as per the PRISMA-statement methodology (PROSPERO: CRD42019138548, August 19th, 2019); methodological quality was assessed using the Appraisal of Guidelines for Research & Evaluation version II system. We developed a RAND/UCLA consensus to support the inclusion of good practice statements and feasibility of selected recommendations.

RESULTS

Thirteen clinical questions were integrated, and fracture risk was selected as the main outcome for intervention recommendations analysis. Six high quality guidelines were selected. We prepared final recommendations from selected guides in an evidence synthesis framework. After the consensus, we integrated 50 recommendations.

CONCLUSION

By starting the adaptation process with ADAPTE, we experienced a time consuming process, which we could overcome when migrating to GRADE-Adolopment in combination with a consensus panel.

Prognostic performance of Predictive Index for Osteoporosis and Osteoporosis Self-Assessment Tool for Asians in the identification of individuals high-risk for osteoporosis

Objectives

To compare Predictive Index for Osteoporosis (PIO) with Osteoporosis Self-Assessment Tool for Asians (OSTA) as a clinical tool for identifying the risk of osteoporosis in Filipino men 50–69 and Filipino women 50–65 years of age.

Methods

This was an analytic study that employed a cross sectional approach that included Filipino men and women seen at the Outpatient Charity Department or at the private clinics and who underwent dual energy X-ray absorptiometry. All subjects completed a structured questionnaire and their weight and height were obtained, from which their PIO and OSTA scores were computed.

Results

A total of 81 patients were included in the study. OSTA has an area under the curve of 0.712 which turns out to be significant (P = 0.0004), with a calculated likelihood ratio of 1.64. The receiver operating characteristic (ROC) curve of PIO showed that the optimal cut off is > 0.962 and the calculated likelihood ratio that this patient may have osteoporosis is 1.38. Comparing the sensitivity and specificity, the resulting P value of 0.2728 denotes that the area under the curve of the 2 tools is not significantly different.

Conclusions

The optimal cut-off point of OSTA and PIO to discriminate high-risk and low-risk patients for osteoporosis were 0.712 and 0.686, respectively, based on ROC analysis. The performance measures of OSTA and PIO did not vary significantly in predicting the risk for osteoporosis in Filipino adults.

Translation, cultural adaptation, and validation of the 10-year Fracture Risk Assessment Tool into Filipino

Introduction:

Screening tools for osteoporosis are relatively expensive and inaccessible to the general Filipino population. This study aims to develop a Filipino version of a validated measure, the Fracture Risk Assessment Tool (FRAX), in order to facilitate improvement of fracture prevention care in the country.

Methods:

The FRAX was translated and culturally adapted into a Filipino version using established forward and backward translation methods and was succeedingly tested for equivalence to the original. The final version was administered to 120 outpatients and was tested for reliability using peripheral dual-energy x-ray absorptiometry (DXA) measurements of the distal radius.

Results:

To be better understood and reliably answered by the Filipino population, several qualifiers were added to items such as previous fracture and rheumatoid arthritis. This was to account for the high incidence of high-energy trauma in the country and the use of the same Filipino term for rheumatoid arthritis (RA) as with other arthritides, respectively.

Conclusion:

The Filipino version of the FRAX appears to be an acceptable and reliable instrument, serving as a low-cost alternative to bone mineral density (BMD) and DXA scans which are generally inaccessible and unaffordable by majority of the populations.

Secondary prevention of fragility fractures in Asia Pacific: an educational initiative

The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.

Osteoporosis in South-East Asian Countries

Osteoporosis (OP) is a condition where there is low bone density and microarchitectural deterioration which can predispose to fragility fractures. There is a wealth of literature on OP from the developed countries, but less so from Asia. This review will explore the field of OP research in South-East Asia with regard to the epidemiology, the diagnosis of OP and the role of laboratory tests in the management of OP, with emphasis on 25-dihydroxyvitamin D and bone turnover markers.

The diversity of Fracture Risk Assessment Tool (FRAX)-based intervention thresholds in Asia

Fracture Risk Assessment Tool (FRAX), introduced in 2008, is the most frequently used fracture risk calculator. Many Asian countries have developed own FRAX models to suit their country needs. Only a few Asian countries, however, have developed country-specific intervention thresholds to demarcate high-risk patients. A wide variation is seen in these intervention thresholds partly due to the different approaches used in developing the cutoff values. This paper discusses the diversity of the intervention thresholds in Asian countries and possible reasons. It also discusses the future directions for the countries in the Asian region.

Nonpharmacological interventions for osteoporosis treatment: Systematic review of clinical practice guidelines

Objectives

The aim of this study was to perform a systematic review of clinical practice guidelines to identify nonpharmacologic recommendations for osteoporosis treatment.

Methods

A systematic review of literature following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-statement methodology for clinical practice guidelines was conducted; PROSPERO CRD42019138548. Assessment of selected clinical practice guidelines with the AGREE (Appraisal of Guidelines for Research & Evaluation)-II methodological quality instrument was performed, and those graded over 60 points were selected for recommendations extraction and evidence analysis.

Results

Only 6 clinical practice guidelines fulfilled criteria, 69 nonpharmacological recommendations were extracted: 13 from American Association of Clinical Endocrinologists and American College of Endocrinology guideline, 16 from Malaysian Osteoporosis Society guideline, 15 from the Ministry of Health in Mexico guideline, 14 from Royal Australian College of General Practitioners guideline, 7 from Sociedad Española de Investigación Ósea y del Metabolismo Mineral guideline, and 7 from National Osteoporosis Guideline Group guideline. Percentage by theme showed that the highest number of recommendations were 12 (17.1%) for vitamin D, 11 (15.7%) for a combination of calcium and vitamin D, and 11 (15.7%) for exercise.

Conclusions

These recommendations address integrating interventions to modify lifestyle, mainly calcium and vitamin D intake, and exercise. Other recommendations include maintaining adequate protein intake, identification and treatment of risk factors for falls, and limiting the consumption of coffee, alcohol and tobacco. Considerations on prescription must be taken.

Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review

PURPOSE

To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making.

METHODS

A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force.

DISCUSSION

Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation

This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific.

INTRODUCTION

In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation.

METHODS

We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds.

RESULTS

Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity.

CONCLUSION

The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.

Osteoporosis management and the utilization of FRAX®: a survey amongst health care professionals of the Asia-Pacific

This survey investigated osteoporosis management practices in the Asia-Pacific region. While access to anti-osteoporotic medication is reasonable, screening for secondary contributors is performed insufficiently. FRAX® is well-known, but not used by many physicians. High costs of medication and unawareness about the disease are the biggest barriers to osteoporosis care.

PURPOSE

Osteoporosis is an increasing burden amongst countries of the Asia-Pacific. The fracture risk assessment tool FRAX® has recently been introduced in some Asian countries. This study aimed to identify attitudes about osteoporosis management in general and the utilization of FRAX® in particular amongst physicians in the Asia-Pacific region.

METHODS

A 26-item questionnaire was distributed to the participants of the first Asian regional osteoporosis meeting of the IOF in 2010. In total, 247 valid questionnaires representing 17 countries from the Asia-Pacific region were analyzed.

RESULTS

Most physicians make use of bone densitometry devices (94 %) and have access to at least one type of anti-osteoporotic medication (100 %). Central dual-energy X-ray absorptiometry was the most accessible device (87 %). Oral bisphosphonates were the only medication that was available to health care professionals in all surveyed Asia-Pacific countries. Seventy-six percent were aware of FRAX®; however, among these only 62 % used it. The main reason for not using FRAX® was the lack of country-specific models (46 %). Screening for secondary osteoporosis was performed by 36 % of the respondents. The high costs of medication and lack of awareness amongst physicians and patients about the disease were perceived as the most important barriers to osteoporosis care.

CONCLUSION

More FRAX® models should be established and implemented into the local guidelines. The necessity of screening for secondary contributors to osteoporosis should be emphasized, as easily treatable causes might be identified. To further improve osteoporosis diagnosis and treatment, the awareness of osteoporosis among doctors as well as patients needs to be raised.